Tests often ordered when not needed

More than 40% of routine office visits for preventive health exams result in physicians ordering unnecessary laboratory tests and procedures, costing as much as nearly $200 million a year, according to a study in the June American Journal of Preventive Medicine. (See correction)

Researchers and experts cited physicians' lack of familiarity with evidence-based guidelines, patient pressure on physicians to order superfluous tests and doctors' fear of medical liability as culprits for the problem.

The study examined data collected as part of the National Ambulatory Medical Care Survey from 1997 to 2002 for office visits where patients said they were visiting for a general exam, the reason listed for the visit by the physician was non-illness care, and the only diagnosis code was for a general medical exam.

Urinalyses, for example, were ordered nearly 37% of the time, even though the U.S. Preventive Services Task Force, an entity within the U.S. Dept. of Health and Human Services, recommends against routinely providing the test to asymptomatic patients. X-rays and electrocardiograms, which the USPSTF also recommends against using as routine screening tools, were each ordered in fewer than 10% of visits.

Complete blood counts, which the USPSTF doesn't recommend for or against, were ordered during 27% of physical exams. Hematocrits, also on a USPSTF list that doesn't recommend for or against, were ordered during 17% of physical exams.

Solely looking at the nonrecommended tests, the price tag for what researchers called overuse was tallied as falling somewhere between $47 million and $194 million in direct costs, with potential follow-up tests for false-positives adding to the price tag, the study showed.

The USPSTF standards are "evidence-based and well-respected," said Dan Merenstein, MD, lead author of the study and director of family medicine research at Georgetown University Medical Center in Washington, D.C. Dr. Merenstein said physicians who are ordering tests for which an evidence base is lacking may be missing other, more valuable tests, such as blood pressure and cholesterol checks.

Why the tests are ordered

Diane B. Petitti, MD, MPH, USPSTF vice chair and senior scientific adviser at Kaiser Permanente Southern in California, said habit is the biggest reason why physicians persist in ordering these tests during routine physicals even though evidence for their effectiveness is lacking.

"When a test is perceived as both cheap and harmless, the fact that it's unnecessary is subject to less scrutiny," Dr. Petitti said.

While previous research has examined both overuse, underuse and variation in other areas, there's been less study of overtesting during routine health exams, said Neal Kohatsu, MD, MPH, president of the American College of Preventive Medicine and an associate epidemiology professor at the University of Iowa College of Public Health.

Dr. Kohatsu said one explanation of the study's finding is some physicians' refusal to wholeheartedly embrace the notion of evidence-based medicine. Another, he said, is that many patients walk in expecting the works.

"The patient may strongly believe that good medicine requires performing as many preventive tests as feasible within a visit," Dr. Kohatsu said."We know that some of those testsare not valuable and potentially harmful."

For example, Dr. Merenstein said urinalysis might seem harmless. But, he said, if it's not indicated it could lead to false positives and cause unneeded anxiety for the patient.

Kevin Pho, MD, a Nashua, N.H., internist and blogger (link), said he's had patients demand nonrecommended tests such as stress tests during a physical examination.

"In most cases, I try to present the evidence from the USPSTF, but at the end the day the final word is always the patient's, " Dr. Pho said.

Knowing the standards

For its part, the USPSTF is attempting to make its recommendations more easily accessible to physicians.

Next month the panel is set to release a 2006 version of its pocket guide to 53 recommended clinical preventive services that includes the Centers for Disease Control Advisory Committee on Immunization Practices immunization schedules for children and adults.

The 2005 version is available online (link).

The USPSTF guidelines are just one of many sets available, according to Richard Anderson, MD, CEO of The Doctors Co., a medical liability insurer based in Napa, Calif.

"Every time you turn around someone's got a new set of practice guidelines," Dr. Anderson said. "And most doctors wouldn't recognize the USPSTF and wouldn't immediately recognize their guidelines as relevant to their practice."

The real guidelines physicians follow, often unconsciously, are the ones judged to be the standard of care by jurors in medical liability trials, Dr. Anderson said.

"Medical standards have migrated to legal standards," he said. "A trial lawyer can always make the case for why you should have gotten additional data."

When asked about the practice of defensive medicine, Dr. Pho responded: "I have not heard of a lawsuit because of overtesting."